The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Attempt to deescalate the client.

Continue to observe the client for increased agitation.

Offer medications to help the client control behavior.

Ensure safety in the environment for the client and others.

Answer and Explanation

The Correct Answer is D

A.   Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B.   Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C.   While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D.   Ensuring the safety of the client and others is the priority in situations of escalating agitation.

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Correct Answer is D

Explanation

A. Anhedonia is a symptom commonly associated with depression, characterized by a decreased ability to experience pleasure or interest in activities.

B. Aphasia is a language disorder that affects the ability to communicate. It may involve difficulty in speaking, understanding language, reading, or writing. This is not demonstrated in the scenario.

C. Akathisia is a side effect of some antipsychotic medications characterized by a feeling of inner restlessness and the need to move constantly. It is not demonstrated in the scenario.

D. Agnosia is a symptom of dementia characterized by the inability to recognize familiar objects, people, or places, despite the senses being intact. In this scenario, the client's inability to recognize that their glasses are not a form of identification indicates agnosia.

A. Do not participate in strenuous activity in the heat. B. Drink adequate amounts of fluid daily. C. Follow a strict low sodium diet. D. Routine blood work will be required. E. Dependency can occur with this medication.

Correct Answer is ["B","C","D"]

Explanation

A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.

B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.

C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.

D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.

E) Incorrect. Dependency is not a common concern with lithium.

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The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

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Naxlex Comprehensive Predictor Exams

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